Clinical Considerations Ingestions of acid and alkali caustics cause immediate severe burning of exposed surfaces, usually with intense dysphagia Associated glottic edema may cause airway obstruction and asphyxia Severe acid ingestions most often cause gastric necrosis and may be complicated by gastric perforation and peritonitis With alkalis, severe damage is more commonly found in the esophagus; deep-tissue injury may quickly lead to esophageal perforation, mediastinitis, and death As already noted, alkalis also produce severe esophageal strictures in survivors Management The initial step in the management of a caustic ingestion is to determine whether the agent is, in fact, caustic and, if so, whether it is an alkaline or acid caustic Many products that are believed to have caustic potential (e.g., household bleach) are simple irritants and not require intervention Identification of ingredients and their caustic potential can be found through consultation with a regional poison control center The management approach to cleaning product and caustic ingestions, as outlined in Figures 102.7 and 102.8 , begins with rapid clinical assessment of cardiorespiratory function, neurologic status, and evidence of GI hemorrhage Life support measures may be needed emergently to secure the airway and to treat shock or metabolic acidosis Do not attempt to dilute or neutralize the agent and not attempt GI decontamination; these may worsen the injury As noted previously, most patients with significant exposures develop symptoms early and may appear critically ill However, even patients with minimal symptoms and the absence of oral lesions may have significant esophageal injury; thus, patients with a history of unintentional ingestion of a caustic substance with any signs and/or symptoms suggestive of possible injury (including, stridor, vomiting, pain, and/or drooling) merit upper GI endoscopy within 12 to 24 hours to be evaluated fully for the presence of esophageal burns Endoscopy is also recommended in all patients with intentional ingestions Endoscopy can classify esophageal burns based on a grading system, as follows: hyperemia or edema without ulceration (Grade I), noncircumferential submucosal lesions, ulcers, and exudates (Grade IIa), near-circumferential submucosal lesions, ulcers, and exudates (Grade IIb), and deep ulcers and necrosis (Grade III) This grading system can help determine prognosis and guide management